April 21, 2023April 21, 2023

Unsafe Abortion Mortality: New Estimates and Trends, Health and

Social Consequences

Presented at the International Presented at the International Interdisciplinary Symposium on Reducing Interdisciplinary Symposium on Reducing Maternal Mortality in sub-Saharan Africa: Maternal Mortality in sub-Saharan Africa:

better understanding for better actionbetter understanding for better actionDakar, Senegal – December 13-16, 2010Dakar, Senegal – December 13-16, 2010

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Professor FE OkonofuaProfessor FE OkonofuaUniversity of Benin, Nigeria University of Benin, Nigeria

April 21, 2023April 21, 2023

Background

The WHO defines Unsafe Abortion as: “A procedure for terminating an unintended pregnancy that is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both¨

Despite increasing prevalence of contraception and the existence of safe and effective methods of abortion, millions of unsafe abortion continue to take place globally each year resulting in increased risks of associated morbidity and mortality

The objective of this presentation is to provide the most recent WHO estimates of unsafe abortion and to elucidate the associated health and social consequences

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Methodology

Review of the most recent WHO publications and database on unsafe abortion and associated mortality

Review of other publications relating to trends in abortion incidence and mortality

Recent papers published by Shah and Ahman in Reproductive Health Matters and Susheela Singh in the Lancet

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Unsafe Abortion in 2008

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WHO estimates that 21.6 million unsafe abortions took place worldwide in 2008, almost all in developing countries

The best indicators for measuring unsafe abortion are:

- Unsafe abortion rate: the number of unsafe abortions per 1000 women aged 15-44

years

- Unsafe abortion Ratio: the number of unsafe abortions per 100 live births

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Estimated Annual Incidence of Unsafe Abortion per 1000 Women Aged 15-44

years, by UN Sub-region, 2008

Number of Unsafe Abortions

(rounded)

Unsafe Abortion Rate (per 1000 women aged 15-44 years)

Unsafe Abortion Ratio (per 100 live births)

World 21,600,000 14 16

More developed regions* 360,000 1 3

Less developed regions 21,200,000 16 17

Least developed countries 5,020,000 27 18

Sub-Saharan Africa 5,510,000 31 17

Africa 6,190,000 28 17

Eastern Africa 2,430,000 36 20

Middle Africa 930,000 36 18

Northern Africa 900,000 18 18

Southern Africa 120,000 9 10

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Contd

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Western Africa 1,810,000 28 16

Asia* 10,810,000 12 14

Eastern Asia* ° ° °

South-Central Asia 6,850,000 17 17

South-eastern Asia 3,130,000 22 28

Western Asia 830,000 16 16

Europe 360,000 2 5

Eastern Europe 360,000 5 12

Northern Europe ° ° °

Southern Europe ° ° °

Western Europe ° ° °

Latin America and the Caribbean 4,230,000 31 39

Caribbean 170,000 18 22

Central America 1,070,000 29 34

South America 2,990,000 32 43

Northern America ° ° °

Oceania* 18,000 8 7

Australia/New Zealand ° ° °

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Estimated Annual Number of Unsafe Abortions, Rates and Ratios, By

Geographical Regions, 2008

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Unsafe Abortion Rates Per 1000 Women of Ages 15-44 For All

Countries

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Estimated Number of Unsafe Abortion Globally and by Major Regions, 2003 and 2008

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Unsafe Abortion Rates Per 1,000 women

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Consequences of Unsafe Abortion

Despite being a simple procedure, one in four women having an unsafe abortion face the risk of severe complications

Worldwide, unsafe abortion account for 13% of maternal deaths, and 20% of overall burden of maternal death and longer term disability as measured in Disability Adjusted Life-Years (DALYs)

Compared with developed countries the burden per 1000 unsafe abortions is more than six times as high in sub-Saharan Africa and four times as high in Asia

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Consequences of Unsafe Abortion

Unsafe abortions accounted for 20,500 maternal deaths in 2005

Among the estimated 358,000 global maternal deaths in 2008, 47,000 were due to complications of unsafe abortion (nearly a doubling)

Over half of these were in Africa, while 34% occurred in the least developed countries

MMR associated with abortion was 650 deaths per 100,000 unsafe in 2003 , compared to 10 per 100,000 in developed countries

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36% The World’s Population Live Where Abortion is Very Restricted

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26%

10%

3%

21%

40%

Prohibited altogetheror only to save life

Physical Health

Mental Health

Socioeconomic

Without restriction

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Restricting Contraception and Legal Abortion In Romania Resulted In Increased Maternal And Abortion-related Deaths

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0

40

80

120

160

200

1960 1964 1968 1972 1976 1980 1984 1988 1992 1996

Maternal and unsafe abortion deaths per 100,000 live births, by year, Romania

Maternal deaths

Abortion deaths

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Distribution of Countries by Number of Deaths due to Unsafe Abortion

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Number ofdeaths per100 000 livebirths

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Distribution of Countries By Number of Deaths Due to Unsafe Abortion

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Region and Sub-region

Number of maternal deaths due to unsafe abortion (rounded)

Deaths due to unsafe abortion (as % of all maternal deaths)

Deaths due to unsafe abortion per 100,000 live births (rounded)

World 70 500 13 55More developed <60 4 . Less developed Countries

70 400 13 60

Least developed countries

24 000 10 85

Less developed regions, excluding China

70 400 13 70

Africa 38 400 14 115Eastern 14 800 17 130Middle 6600 11 130Northern 1200 11 25Southern 500 9 40Western 15 300 13 140

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Estimates of Deaths due to Unsafe Abortion in 2005 in three countries

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Annual number of women treated in hospital for induced abortion complications

Annual hospitalization rate for induced abortion complications per 1000 women

Egypt 216 000 15.3

Nigeria 142 200 6.1

Uganda 85 000 16.4

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Health Consequences Are Often Severe And Can Be Long-term

Kenya: 28% of post-abortion patients experienced severe complications

Nigeria: among hospitalized patients, one in 3 had hemorrhage, one in four sepsis and about 1 in 10 had injury to other organs

Abortion in the second trimester greatly increases risk

There are many long-term consequences

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Additional Consequences

Loss of productivity

Increased economic burden and cost to the public health system

Social & cultural stigma

Long term ill-health, including infertility

Overall , some 24 million women are estimated to be currently suffering from secondary infertility due to

unsafe abortion

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Contraception is Key to Prevention Of Unsafe Abortion

It is well documented that family planning programs reduce abortion

There can be a lag: the desire for small families may increase faster than contraceptive use

But contraception does not eliminate the need for safe abortion, and there are several other reasons why women result to abortion

Governments and stakeholders must improve access to contraceptive information and services

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Prevention of Unsafe Abortion Includes More than Contraception

Access to safe and legal abortion is the most fundamental means of prevention

Also important are use of safer techniques and training of providers in these techniques

Manual vacuum aspiration is effective and suitable for low resource settings

Early medication abortion is a new and recommended technique

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Prompt And Appropriate Treatment Of Complications Is Also Important

WHO has issued guidelines for provision of safe abortion care & treatment of complications

Post abortion contraceptive counseling and services are essential

Rapid transfer to tertiary care can be lifesaving

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The Public Health Imperative

The rationale for making safe abortion available is well established

The public health record is clear and incontrovertible: access to safe, legal abortion improves health

Cairo, 1994:”In circumstances where abortion is not against the law, such abortion should be safe.”

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Dealing with Unsafe Abortion in Africa

The Maputo Plan of Action Enact policies and laws to reduce the incidence of unsafe

abortion

Prepare and implement national POA to reduce the incidence of unwanted pregnancies & unsafe abortion

Provide safe abortion services to the fullest extent of the law Educate communities on available safe abortion services as

allowed by natural laws Train health providers in prevention and management of unsafe

abortion

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Mahmoud Fathalla Sums Up The Situation Very Well

“Pregnancy-related deaths are often the ultimate tragic outcome of the cumulative denial of women’s human rights. Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”

Simply put, they die because they do not count.

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Some References:

Shah H, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences and challenges. J Obstet Gynecol Can 2008; 31: 1149-1158.

Singh S. Hospital Admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006; 368: 1887-1892.

Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH. Unsafe abortion: A preventable pandemic. Lancet 2006 (Special Edition): 65-76.

Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet 2007, 370, 1338-1345

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Acknowledgements

Dr Alain Prual of UNFPA,

and

Dr Brooke Levandowski of Ipas, USA

For sharing some of the reading

materials with me.

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Thank youThank you

Merci Merci

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